ADHD – it’s an alphabet soup name that conjures up images of fidgety, impulsive kids bouncing off walls and ceilings as if they were jumping on an invisible trampoline. It is not generally recognized that adults too can be candidates for a diagnosis of ADHD. But if you have the attention span of a squirrel and find your mind always wandering when it is required to be “deep-listening”, if you have trouble waiting for things to happen or being patient, if you have high-octane levels of energy, if you’re bored too easily, if you are often told that you “act without thinking”, if your mind is clogged with the minutiae of life (“Where’s my keys?”, “Where’s my wallet?”, “Where’s my cellphone?”), if you see yourself as unreliable and feel the shame of being so, you might want to consider this possibility: Could you be having adult ADHD?
The existence of adult ADHD as a distinct psychiatric entity is well established today. The conventional wisdom is that either ADHD that has been diagnosed in childhood continues through the teen years and into adulthood, or that some children who may not have been diagnosed during childhood get a diagnosis when they are adults. But two large-scale studies published in JAMA Psychiatry last year suggest a third possibility: that, in most cases of adult ADHD, the condition may not have existed in childhood but has instead developed only in adulthood. The studies tested over 7000 children at various stages in childhood and then re-tested them at age 18; both studies found that the majority of adults who met diagnostic criteria for ADHD (68 per cent in one study and 87 per cent in the other) did not have symptoms as children. The authors hypothesize that the demands of a college education or the stress of supporting themselves exposes some people’s symptoms as they enter adulthood, or that a distinct adult version of ADHD may exist.
If these findings hold up in further research, it may require a new perspective on ADHD, one which recognizes that some people may begin struggling with ADHD only in adulthood. Overall, ADHD is believed to affect 2 to 6 per cent of all adults. Many adults with ADHD aren't aware they have it — they just know that everyday tasks can be a challenge.
Getting a diagnosis
ADHD manifests as a persistent pattern of:
1. Inattention; and / or
2. Hyperactivity- impulsivity.
There is no single test to diagnose ADHD. And diagnosis is made more challenging by the fact that many other problems, like anxiety, depression or conduct disorder, can have similar symptoms. So can medical problems like thyroid malfunction, a seizure disorder, brain injury, lead poisoning, a sleep disorder or low blood sugar. These conditions must be first ruled out by a doctor.
A person with adult ADHD will generally come seeking help with a presenting problem of stress or anxiety or a mood disorder like depression. The diagnosis can be made by a mental health professional like a psychologist or a psychiatrist. Screening tools (usually a questionnaire or self-test) are complemented by interviews and assessments.
Mental-health professionals use specific criteria as an aid to diagnosing ADHD. While in the case of children at least six symptoms of inattention and / or hyperactivity (see the list, below) must be met to support a diagnosis of ADHD, in the case of adults, only 5 criteria need to be met.
» Often fails to give close attention to details or makes careless mistakes at work, or in other activities.
» Often has trouble sustaining attention during activities such as listening to a conference presentation or lengthy reading
» Often does not seem to listen when spoken to directly
» Often does not follow through on instructions and fails to finish duties in the workplace or other kind of tasks (e.g., loses focus, side-tracked)
» Often has trouble organizing tasks and activities -- for example, is messy and has poor time management
» Often avoids, dislikes, or is reluctant to carry out tasks that require mental effort over a long period of time (such as research work for a project)
» Often loses things necessary for tasks and activities (e.g. wallet, keys, spectacles, cellphone)
» Is easily distracted by unrelated thoughts or stimuli
» Is often forgetful in daily activities such as paying bills, keeping appointments or returning calls
Hyperactivity and Impulsivity
» Often fidgets with or taps hands or feet, or squirms in seat
» Often leaves seat in situations when remaining seated is expected
» Feels restless or is unable to be still for extended periods of time
» Has difficulty taking part in leisure activities quietly
» Is often “on the go”, or acting as if “driven by a motor”
» Often talks excessively
» Often blurts out an answer before a question has been completed
» Often has trouble waiting his/her turn, such as when standing in line
» Often interrupts or intrudes on others (e.g., butts into conversations)
In addition to the above criteria, the mental health professional will also check that the following conditions are met:
» At least 5 of the above symptoms must have been present in a persistent and ongoing pattern.
» The symptoms must be present in two or more settings, such as at home and at work.
» There must be evidence that the symptoms interfere with the person's functioning in these settings.
» The symptoms are not better explained by another mental disorder (such as a mood disorder like depression or bipolar, an anxiety disorder or a personality disorder).
ADHD symptoms might look different at older ages. For example, in adults, hyperactivity may appear as extreme restlessness or wearing others out with their activity; in children, it may present as running about or climbing a lot or making a great deal of noise.
Also, since adults are more mature than children and teens, they may be able to better control their symptoms of ADHD. But this is not always so, and some adults continue to have major problems that interfere with daily functioning.
Causes and Risk factors
While no single cause for ADHD has been discovered, there are biological and social risk factors that increase the probability of someone developing the condition. Brain-imaging studies indicate that the brains of people with ADHD have a tendency to be smaller, to have fewer connections between certain brain areas, and to have less regulation of the neuro-chemical, dopamine, compared to people who do not have the disorder. One study has found that the amount of gray matter in the brain may contribute more to ADHD than levels of dopamine.
There seems to be a strong genetic link. Those with parents or siblings with ADHD are more likely to develop it themselves.
It’s not currently clear what role environmental factors play in determining who develops ADHD, but research in this field continues apace. A strong association has been established between ADHD and exposure to lead during childhood; other toxins are also being investigated.
The prenatal environment is another area of concern. The risk for ADHD is thought to increase if the mother had smoked, drunk alcohol or used drugs during pregnancy. A premature birth is another possible contributor to ADHD risk.
ADHD seldom comes calling alone
Though ADHD does not cause another psychological disorder, very often there is likely to be one or more additional mental health conditions co-occurring with the ADHD (called “co-morbid conditions”). While very few studies of adult ADHD have been done in India (or, for that matter, in Asia, overall), a 2009 study of Indian men with ADHD found that 80 per cent of the men diagnosed with ADHD had co-morbidity, such as major depressive disorder, substance abuse or oppositional defiant disorder (ODD). The study was carried out by the C. S. M. Medical University, Lucknow (formerly King George’s Medical University) and St George Hospital, Australia.
Other mental health conditions that may co-exist with ADHD include anxiety disorders, personality disorders and intermittent explosive disorder. Learning disabilities may also be present in adults with ADHD. They may score lower on academic testing than would be expected for their age, intelligence and education. Other learning difficulties may include problems with understanding and communicating. In most cases of Adult ADHD, the co-morbid disorders tend to persist across a lifetime.
The fact that those coping with adult ADHD include high achievers like Virgin founder and adventurer Richard Branson, the most decorated Olympian of all time, swimmer Michael Phelps, Grammy-winning singer-songwriter Justin Timberlake, and actors Jim Carrey and Will Smith, should not make us overlook the fact that most adults with uncontrolled symptoms of ADHD have a moderate to serious level of difficulty in functioning. These difficulties run a wide gamut, including:
» Difficulty finding and keeping jobs
» Performance below their level of competence and intelligence – e.g., missed deadlines on projects, caused by procrastination; forgetting important meetings
» Problems with co-workers
» Problems in other inter-personal relationships (e.g., with spouse, relatives and friends)
» Problems while driving a vehicle – e.g., impatience in waiting for the green signal; taking unjustified risks while driving; proneness to road rage; accidents
» Difficulties in coping with other adult responsibilities such as handling finances.
» Trouble with the law – e.g., if impulsive outbursts of anger lead to violence against another person.
» Alcohol or other substance abuse.
Treatment for Adult ADHD
As with children and teens, stimulant drugs are the primary medical treatment for ADHD in adults. You might think that stimulant drugs would be the very last thing that could help someone who already seems over-stimulated. However, these drugs do have this seemingly paradoxical effect. They work by increasing dopamine and thereby stimulating focus. About two-thirds of adults with ADHD who take these medications show significant improvement in ADHD symptoms. However, a word of caution: taking higher than the prescribed levels of medication will not lead to greater focus and attention. If dopamine levels are too high, it can make it difficult for you to focus.
Other drugs may also be prescribed; they include non-stimulants and certain anti-depressants. These drugs work more slowly than stimulants do, but they may be good options if you can't take stimulants because of health problems or a history of substance abuse or if stimulants cause severe side- effects.
But drugs are not a cure, and a multi-modal approach is needed for the successful management of ADHD. Psychotherapy is an important part of the treatment process. This is put to work at various levels:
» Education about the disorder
» Training in a wide variety of life skills – e.g., time management and organizational skills; problem-solving skills
» Behaviour therapy, which helps you develop strategies to control your anger, learn how to reduce your impulsive behaviour, change negative thinking patterns into positive ones, among other things.
» Couples therapy and / or family therapy. This type of therapy can help loved ones cope with the stress of living with someone who has ADHD and learn what they can do to help.
What doesn’t work?
Beware of unproven treatments. There are many unfounded “cures”, such as vision training, vitamins, biofeedback, spinal cranial manipulation and anti-ADHD diets. To date, we have little research evidence on the effectiveness of home remedies like dietary restrictions and vitamin supplements for ADHD. Some other claims of “cures” have been well and truly debunked. You need to research treatments and inform your doctor of any alternative therapies you might be considering.
However, some research suggests that physical activity may stimulate parts of the brain that have been associated with ADHD. At the very least, exercise can help you channel extra energy. At a different level, regular exercise and team sports can also help you work together with others, learn to set and meet goals, and feel better about yourself. Michael Phelps is on record saying that he channelled his restlessness into swimming and that, “with continuous praise and positive reinforcement”, he found the encouragement he needed to fight on to victory and gold. But swimming, he stressed, was not just a winning sport for him, it was (and is) a way for him to cope with his ADHD.